Provider Demographics
NPI:1578550729
Name:MOMS PHARMACY INC
Entity Type:Organization
Organization Name:MOMS PHARMACY INC
Other - Org Name:MOMS PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP, CFO
Authorized Official - Prefix:
Authorized Official - First Name:RUSS
Authorized Official - Middle Name:
Authorized Official - Last Name:FICHERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-870-5126
Mailing Address - Street 1:PO BOX 637302
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:631-547-6520
Mailing Address - Fax:206-202-4127
Practice Address - Street 1:45 MELVILLE PARK RD
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3109
Practice Address - Country:US
Practice Address - Phone:631-547-6520
Practice Address - Fax:631-249-5865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X, 3336S0011X
NY0211583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02533719Medicaid
3323324OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NJ0023990Medicaid
CT003111672Medicaid